Ohio Cyber Academy Enrollment Form

Enrollment Form
Student Information
Student's Legal Name*

First NameMiddle NameLast Name
Grade Level*
Gender
Birthdate*

MonthDayYear
Date
Birth City*
*Birth City is required solely to obtain a confidential student identification number.
Is the student identified as:

Special Ed (IEP)On a 504 planGiftedEL
Is the student currently:
Admission Reason:

Enrolled 1st time in an Ohio public/community schoolTransferred from homeschool (not online school)Transferred from out of state or countryTransferred from non-public schoolTransferred from another Ohio public, community or online schoolNot enrolled in an Ohio public/community school since 2003 for a reason not listed aboveExchange student
If you checked the box (transferred from non-public school) please enter the school name:
If you checked the box (transferred from another Ohio public, community, or online school) please enter the school district name:
**Grade placement subject to adjustment upon receipt of previous school records.
Required by the U.S. Department of Education
Race/Ethnicity:
Is the student Hispanic/Latino?
What is the student's race? (Choose all that apply):

AsianBlack or African AmericanAmerican Indian or Alaskan NativeNative Hawaiian or Pacific IslanderWhite
Home Internet Access
Select the option that best describes how you receive you home internet service. (Choose only one.)
Household Information:
Residence address of student

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ohio County in which the student resides:
Primary Phone:
Please enter a valid phone number.
Student resides with:
**Please provide all legal documentation for divorce/custody/guardianship. **Student must provide proof of emancipation.

Cancelof
If student resides with anyone checked above, other than Mother and/or Father, you would like to disclose that information, please list their name, relationship to the student, and emergency contact number.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Mother/Guardian Information:
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to Student:
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email
example@example.com
Living with Student?
Active Military?
Address (If different than student)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father/Guardian Information:
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to Student:
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email
example@example.com
Living with Student?
Active Military?
Address (If different than student)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List all other siblings or step-siblings under the age of 22 who reside in the students' home. (Name, Gender, DOB)
Should be Empty:

Enrollment Form

Student Information

Required by the U.S. Department of Education

Home Internet Access

Household Information: